| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $12 | $12 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $160 | $160 | $160 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $222 | $222 | $222 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $222 | $222 | $222 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $364 | $364 | $364 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $222 | $222 | $222 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $202 | $202 | $202 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $401 | $401 | $401 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $303 | $303 | $303 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $243 | $243 | $243 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $243 | $243 | $243 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $667 | $667 | $667 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $413 | $413 | $413 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $789 | $789 | $789 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,592 | $1,592 | $1,592 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,867 | $1,867 | $1,867 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $485 | $485 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $4 | $4 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $62 | $62 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $61 | $61 | $61 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $224 | $224 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $46 | $46 | $46 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $53 | $53 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $92 | $92 | $92 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $251 | $251 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $285 | $285 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $29 | $29 | $29 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $9 | $9 | $9 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $28 | $28 | $28 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $24 | $24 | $24 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $61 | $61 | $61 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $71 | $71 | $71 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $95 | $95 | $95 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $104 | $104 | $104 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $41 | $41 | $41 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $100 | $100 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $44 | $44 | $44 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $97 | $97 | $97 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $54 | $54 | $54 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $66 | $66 | $66 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $73 | $73 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $105 | $105 | $105 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $98 | $98 | $98 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |